Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial

Comparison of ultrasound-guided suprainguinal fascia iliaca compartment block and pericapsular nerve group block for postoperative analgesia and associated cognitive dysfunction following hip and proximal femur surgery

Background and Aims

Hip and proximal femur fractures in any age group require surgical reduction and fixation. Various regional techniques are popular for lower limb surgeries but adequate analgesia from these blocks is variable depending upon the type of surgery. We conducted a study to compare ultrasound-guided suprainguinal fascia iliaca compartment (SFIC) block and pericapsular nerve group (PENG) block for postoperative analgesia and cognitive dysfunction in patients undergoing hip and proximal femur surgery.

Material and Methods

Sixty-six patients, aged 18-65 years, American Society of Anaesthesiologists I and II undergoing hip and proximal femur surgery were randomized into two groups, group F for SFIC block (n = 33) and group P for PENG block (n = 33). After completion of surgery, an ultrasound-guided SFIC or PENG block was given. Visual analogue scale (VAS) score on movement and rest, muscle power (quadriceps strength), time to first rescue analgesia, total analgesic requirement, and postoperative cognitive dysfunction in the first 24 h were observed.

Results

A total of 66 patients participated in the study and 30 in each group were analyzed. VAS score at movement was significantly lower (P = 0.018) with better quadriceps muscle strength (P = 0.001) in the PENG block compared to the SFIC block group at 24 h postoperatively. Total opioid consumption in morphine equivalents (P = 0.03) was lower in the PENG block than in the SFIC block group for 24 h (28.5% vs. 71.4%). Cognitive impairment was comparable in both groups (3.3% vs. 16.7%, P = 0.097).

Conclusions

PENG block is better than SFIC block for postoperative analgesia with lesser opioid consumption, whereas postoperative cognitive dysfunction was comparable in both groups.

Effects of Intraoperative Local Pain Cocktail Injections on Early Function and Patient-Reported Outcomes: A Randomized Controlled Trial

OBJECTIVE

To determine whether a perioperative pain cocktail injection improves postoperative pain, ambulation distance, and long-term outcomes in patients with hip fracture.

DESIGN

Prospective, single-blinded, randomized controlled trial.

SETTING

Academic Medical Center.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty.

INTERVENTION

Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI).

MAIN OUTCOME MEASUREMENTS

Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, postoperative ambulation, Short Musculoskeletal Function Assessment.

RESULTS

Seventy-five patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared with the control group on postoperative day (POD) 0 ( P < 0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 ( P < 0.01). Patient ambulation distance was greater on POD 2 ( P < 0.01) and POD 3 ( P < 0.05) in the HiFI group. The control group experienced more major complications ( P < 0.05). At 6-week postop, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The Short Musculoskeletal Function Assessment bothersome index was also significantly lower for patients in the HiFI group, P < 0.05.

CONCLUSIONS

Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health-related quality of life after discharge.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The comparison of postoperative analgesic efficacy of three-in-one-block versus fascia-iliaca blocks following femoral fracture orthopedics surgical procedures under spinal anesthesia, Gondar, Ethiopia, 2021: A prospective cohort study

INTRODUCTION

Femoral bone fracture is the predominant, lower limb orthopedic surgery that is associated with severe acute and persistent chronic pain that needs better postoperative pain management. Untreated postoperative pain results inability to do physiotherapy resulting in stiffens of joints and immobility. This study aimed to compare the postoperative analgesic efficacy of three-in-one-block versus fascia iliaca block in patients who underwent surgically treated femoral fractured patients under spinal anesthesia.

METHODS

A prospective cohort study was conducted on 110 elective surgically treated femoral fractured orthopedic patients from January to October 2021. Data were entered into epi-data 4.4.2 and imported into a statistical package of social science version 22 for analysis. Shapiro-Wilk normality test was used to check the normality of the data and normally distributed data were analyzed using Student's independent t-test, whereas non-normally distributed variables were analyzed with Mann-Whitney U-test. The comparisons of categorical parameters were analyzed using the chi-square test and Fisher's exact test. Finally p-value < 0.05 was declared to be statistically significant.

RESULT

The median and interquartile range of the postoperative numerical rating scale at rest and on movement was significantly less in three-in-one-block (3IN1B) as compared with fascia-iliaca block (FICB). But at 30 min no significantly different between the two pain management modalities. Moreover, the meantime to seek the first request of analgesia was significantly prolonged in 3IN1B compared with FICB. Regarding the total analgesic consumption, the mean total tramadol consumption was 97. 27 ± 53. 07 and 180 ± 72.96 (p < 0.001) and Diclofenac 53.18 ± 29.28 and 72 ± 43.54 (p < 0. 001) in 3IN1 and FICB, respectively.

CONCLUSION

The present study concludes that three-in-one-block provides more effective analgesia, reduced postoperative analgesic requirements, and prolonged first analgesics requests compared with fascia iliaca block, and Landmark technique fascia-iliaca block (FICB) is an alternative pain management modality in a resource-limited setting.

The effect of skin traction on pain relief in patients with isolated intertrochanteric fractures, a randomized clinical trial

BACKGROUND

Hip fractures are common in elderly patients. The surgery is usually delayed due to underlying conditions, and pain control is crucial while the patient is cleared for surgery. In this randomized controlled trial (RCT) study, we hypothesized that the application of skin traction in patients with intertrochanteric fracture does not significantly change the Visual Analogue Score (VAS) of pain.

METHODS

This is a prospective, single institution, parallel randomized controlled trial. Two hundred and twenty-nine patients with isolated intertrochanteric fractures were enrolled in the study. Patients with neurologic issues, drug addiction, scars or swelling, or vascular issues at the site of skin traction application were excluded from the study. Patients were divided into two groups: group A included 97 patients, and group B included 95 patients. Skin traction was applied for group A, while only a soft pillow was put beneath the patients' knees in the other group. The VAS score was measured after the diagnosis, two hours before the operation, and 24 h after the surgery. The morphine dosage administered per day was documented for both groups.

RESULTS

After excluding patients with postoperative delirium, 154 patients (55 males and 99 females) with isolated intertrochanteric fractures (69 right-sided and 85 left-sided), and a mean age of 70 ± 10 remained in the study. There were no significant differences between the two groups regarding age, gender, and mean time from injury to admission (P > .05). The mean VAS score measures and morphine dosage administered per day were not significantly different between the two groups (P > .05). Both groups experienced significant pain relief 24 h postoperatively (P < .001).

CONCLUSION

Pre-operative skin traction application affected neither the patients' VAS scores nor the mean morphine dosage per day in patients with isolated intertrochanteric fractures. Our data does not support the routine application of pre-operative skin traction in patients with intertrochanteric fractures.

TRIAL REGISTRATION

The project was registered in the Iranian Registry of Clinical Trials (registration reference: IRCT20180729040636N3, registration date: 01/07/2020).

LEVEL OF EVIDENCE: 1

Effect of Ultrasound-Guided Fascia Iliac Compartment Block with Nalbuphine and Ropivacaine on Preoperative Pain in Older Patients with Hip Fractures: A Multicenter, Triple-Blinded, Randomized, Controlled Trial

INTRODUCTION

Pain management for older patients with hip fractures is challenging. This study aimed to investigate the effect of ultrasound-guided fascia iliac compartment block (UGFICB) using different doses of nalbuphine in combination with ropivacaine on preoperative analgesia in older patients with hip fractures.

METHODS

In this multicenter randomized controlled trial, 280 elderly patients with hip fracture were randomly allocated into four UGFICB groups (n = 70 in each group): a ropivacaine group (30 mL 0.1% ropivacaine + 0.9% normal saline) and three ropivacaine plus nalbuphine groups (5, 10, and 20 mg nalbuphine, respectively). The primary outcomes were the duration of analgesia at rest and on passive movement. Secondary outcomes included sensory block area, side effects, and vital signs. The doses of rescue analgesia with parecoxib sodium were also analyzed.

RESULTS

The addition of nalbuphine dose-dependently increased the duration of analgesia at rest and on passive movement (P < 0.05) and expanded the area of sensory block (P < 0.05). Compared with the ropivacaine group, the pain scores at rest and on movement at 6 and 8 h after the block were lower in three ropivacaine plus nalbuphine groups (P < 0.05), without between-group differences at 2, 4, and 12 h. The four groups had comparable side effects (nausea and vomiting) and vital signs (P > 0.05).

CONCLUSIONS

UGFICB with 5, 10, and 20 mg nalbuphine added to ropivacaine prolonged the analgesia duration, increased sensory block area, reduced pain, and decreased the doses of rescue parecoxib sodium for older patients after hip fracture, without obvious side effects. Among these three doses, nalbuphine 20 mg in combination with ropivacaine provided the longest duration of analgesia and the largest sensory block area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000029934).

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures

Background

Intertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine.

Methods

This is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05.

Results

Although the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine.

Conclusions

Despite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion.  PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients.

METHODS

The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05).

RESULTS

Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients.

CONCLUSIONS

Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.

Ultrasound-guided anterior iliopsoas muscle space block versus posterior lumbar plexus block in hip surgery in the elderly: A randomised controlled trial

BACKGROUND

Ultrasound-guided posterior lumbar plexus block is widely used for hip fracture surgery but it requires a change of position, which may be painful.

OBJECTIVES

Our primary objective was to describe a new technique, the anterior iliopsoas muscle space block, which can be performed in the supine position, and to test the hypothesis that its analgesia for hip surgery was similar to that of the traditional posterior lumbar plexus block.

DESIGN

Randomised, double-blind study.

SETTING

Shanghai 6th People's Hospital, China, from February to August 2019.

PATIENTS

Forty-eight patients scheduled for unilateral hip fracture surgery were included in the study. The exclusion criteria were infection at the puncture site, history of hip surgery, pre-existing neurological deficits of the lower extremity, contraindications for regional anaesthesia, allergy to local anaesthetics, coagulopathy, abuse of medicine or alcohol, or daily consumption of analgesics.

INTERVENTIONS

Patients were randomised to receive a lateral sacral plexus block with either an anterior iliopsoas muscle space block or a posterior lumbar plexus block, using 0.33% ropivacaine (30 ml each).

MAIN OUTCOME MEASURES

The main outcome was verbal numerical scale (VNS) pain intensity 1 h after surgery in the postanesthesia care unit, and the secondary outcome was the dose of intra-operative fentanyl. The differences in VNS scores and fentanyl use between the groups were analysed.

RESULTS

Based on previous work, we considered a difference (confidence interval [CI]) of 1.6 on the VNS to be significant. The median [IQR] pain scores in postanesthesia care unit were similar in the anterior 0 [0 to 3] and posterior groups 1.5 [0 to 3]. The median scores for intra-operative fentanyl use were similar in the anterior 20 [10 to 42.5] μg and posterior groups 15 [0 to 50] μg (P = 0.34). The difference in the median pain score at-rest was NS: anterior group 0.5 [0 to 5], posterior group 0 [0 to 2], median difference -0.5 (95% CI -2 to 0). The median post to preblock difference in VNS was higher in the anterior -0.5 [-2 to 0] than in the posterior group 0 [-1.25 to 0], median difference 0.5 (95% CI 0 to 1). The median block onset time was longer in the anterior 11 [6 to 14.25] min than in the posterior group 6 [4.75 to 8] min (P = 0.002), median difference -5 (95% CI -7 to -1).

CONCLUSION

The anterior iliopsoas muscle space block had the same effect as the posterior lumbar plexus block on peri-operative analgesia for hip surgery, but with a longer onset time. Therefore, anterior iliopsoas muscle space block can be recommended as a routine technique for hip and lower limb procedures.

TRIAL REGISTRATION

http://www.chictr.org.cn identifier: ChiCTR1900021214.

Comparison of the Effectiveness of Suprainguinal Fascia Iliaca Compartment Block and Patient-Controlled Analgesia for Major Hip Surgeries in Elderly Patients

OBJECTIVE

Fascia iliaca compartment block is an alternative analgesic technique for hip surgeries. In the new suprainguinal technique, the 'bowtie' sign is detected with an ultrasound probe, and local anaesthetic is injected into the fascial plane with in-plane approach. In this retrospective study, we compared the postoperative analgesic efficacy of suprainguinal fascia iliaca compartment block (S-FICB) and patient-controlled analgesia (PCA) after major hip surgery in elderly patients.

METHODS

We retrospectively recorded visual analogue scale (VAS) scores, morphine consumptions and opioid side effects who underwent either a S-FICB (n=67) or PCA (n=61). In the S-FICB group, 25-40 mL of 0.25% bupivacaine was administered with a single-shot S-FICB technique after induction of anaesthesia. VAS scores during resting (VAS-S) and movement (VAS-D); morphine consumption at 0, 6, 12, 24 and 48 hours; total morphine consumption; and opioid-related complications were recorded.

RESULTS

Morphine consumptions in each measurement period and in total were significantly lower in the S-FICB group (694.03±2,007.47 μg vs. 13,368.85±4,834.68 μg; p<0.05). The total number of opioid-related complications were also significantly lower in the S-FICB group (17/67 vs. 48/62; p<0.05). More than half of the patients (38/67, 56%) did not need morphine administration in the S-FICB group. VAS-S during the first 6 hours and VAS-D up to 24 hours postoperatively were significantly lower in the S-FICB group (p<0.05).

CONCLUSION

In our study, S-FICB provided better analgesia than the PCA technique after hip surgery in elderly patients. Moreover, S-FICB reduced opioid consumption and opioid-related complications in the first 24 hours postoperatively.

Peripheral nerve blocks for hip fractures in adults

BACKGROUND

This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.

OBJECTIVES

To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018.  AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.

Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials

Background

With continuous increase of the aging population, the number of geriatric patients with fragility hip fractures is rising sharply, and timely surgery remains the mainstay of treatment. However, adequate and effective pain control is the precondition of satisfactory efficacy. This systematic review aimed to summarize the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures.

Methods

PubMed and Embase databases were searched for English published randomized controlled trials (RCTs) reporting application of FICB for pain control of the older adults with hip fractures between January 1^st, 2000, and May 31^st, 2020. The modified Jadad scale was used to evaluate quality of the RCTs included. Primary outcomes of the eligible RCTs were presented and discussed.

Results

A total of 27 RCTs with 2478 cases were included finally. The present outcomes suggested, after admission or in the emergency department (ED), FICB can provide patients with equal or even better pain relief compared with the conventional analgesia methods, which can also reduce additional analgesic consumptions. While, before positioning for spinal anesthesia (SA), FICB is able to offer superior pain control, facilitating SA performance, after surgery FICB can effectively alleviate pain with decreased use of additional analgesics, promoting earlier mobilization and preventing complications.

Conclusions

FICB is a safe, reliable, and easy-to-conduct technique, which is able to provide adequate pain relief during perioperative management of geriatric patients with hip fractures.

Management of Pain Associated with Fractures

PURPOSE OF REVIEW

The purpose is to review current literature on pain management strategies from initial presentation to postoperative care on common fracture types.

RECENT FINDINGS

- Hip fractures benefit from use of multimodal pain control for early mobility and decreased narcotic requirement. - Distal radius fracture pain during reduction can be managed with hematoma block. Postoperatively, a soft dressing is adequate, and use of a compression glove may improve pain control and edema. - Ankle fractures can be reduced with hematoma block, though use of procedural sedation may reduce reduction attempts for fracture dislocations. - Long bone fracture pain management is trending toward multimodal pain control. Though there is no high-quality evidence, concern that regional anesthesia may mask compartment syndrome has limited its use in high-risk fractures. - The effect of NSAIDs on bone healing has not been conclusively demonstrated. The literature is still inconclusive regarding superiority of either spinal or general anesthesia during operative treatment. Fracture pain control is complex and multifactorial, requiring nuanced clinical judgment in the face of mixed clinical findings.

Results after introduction of a hip fracture care pathway: comparison with usual care

Background and purpose - We established a care pathway for hip fracture patients, a "Hip Fracture Unit" (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods - The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results - Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. "Short Physical Performance Battery" score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.

Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial

BACKGROUND

Managing pain during movement after hip fracture surgery is important for achieving earlier hip mobilisation and for preventing postoperative complications. In the present study, we tested the hypothesis that the fascia iliaca compartment block (FICB) would improve postoperative pain on movement compared with intravenous acetaminophen.

METHODS

In this prospective, randomised, controlled, parallel trial, patients were assigned to either the intravenous acetaminophen or the ultrasound-guided FICB group. Visual analog scale (VAS) pain scores were evaluated at 6, 9, 12, 18, 24 h, 2 days, and 7 days postoperatively. The primary outcome was VAS scores on movement at 24 h after surgery. The secondary outcomes were VAS scores on movement at the other time points, VAS scores at rest, the total number of rescue analgesics required and incidence of delirium during the first 24 h postoperatively, potential drug or block-related complications, and the time to first standing.

RESULTS

VAS scores on movement at 24 h after surgery were significantly lower in the FICB group than in the intravenous acetaminophen group [median (the 25th to 75th percentiles), 20 (10-30) vs 40 (30-53); P < 0.01]. The VAS scores on movement at any other time point and the scores at rest at 12 h after surgery were also significantly lower in the FICB group than in the intravenous acetaminophen group. The two groups did not differ in terms of the total number of rescue analgesics required or the incidence of delirium during the first 24 h postoperatively; complications; or the time to first standing.

CONCLUSIONS

FICB improved postoperative pain on movement compared with intravenous acetaminophen without increasing the complication rate. However, the total number of rescue analgesics required and the time to first standing were not significantly different between the two groups.

The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis

Purpose

Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients.

Methods

PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity.

Results

A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1–8 h (WMD = − 0.78, 95% CI [− 1.01, − 0.56], P = 0.000), 12 h (WMD = − 0.69, 95% CI [− 1.22, − 0.16], P = 0.011), and 24 h (WMD = − 0.46, 95% CI [− 0.89, − 0.02], P = 0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P < 0.05). There was no significant difference between the VAS pain score at 48 h and risk of fall between the FICB and the control groups (P > 0.05).

Conclusions

FICB could be used to effectively reduce pain intensity up to 24 h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1053-1) contains supplementary material, which is available to authorized users.